Ccc2012 HF Wkshop

CCS HEART FAILURE WORKSHOP
THE PRACTICAL MANAGEMENT OF HEART FAILURE 2012 UPDATE
WELCOME!
Learning Objectives
At the conclusion of this workshop, participants will be able to: 1. Review changes and updates for optimal management of chronic and acute heart failure; updating 2006 recommendations to 2012 context and environment; 2. Discuss exercise for heart failure patients - where to begin, what to do and where to end; and 3. Identify opportunities and challenges of surgery for patients with an ischemic etiology for heart failure.
Heart Failure Guidelines
Acute Heart Failure
What is heart failure?

Chronic Heart Failure (CHF):
Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion.
Acute Heart Failure Syndrome (AHF):

gradual or rapid change in heart failure signs and symptoms resulting in the need for urgent therapy
Classification of AHF
high BP, +/- preserved LV systolic fxn; increased sympathetic tone with HR, vasoconstriction; may be euvolaemic or only mildly hypervolemic, and frequently with signs of pulmonary or systemic congestion
usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion.
Severe respiratory distress, RR, orthopnea, rales. O2 sats <90% RA prior to O2 Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT).
Usually sys BP <90 mmHg or drop in MAP >30 mmHg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly
low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures
ESC 2008
Has care evolved?

1950 Morphine Sedation Oxygen Dietary sodium restriction Strict bed rest Digitalis Mercurial diuretics Venesection Inotropes Diuretics Vasodilators Dietary sodium restriction Oxygen? Dietary sodium restriction? Early mobilization Avoid inotropes ?Diuretics ?Vasodilators Morphine 1974 Morphine? 2012
Harrisons Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501
CASE 1
74 year old female 2 months worsening SOB/orthopnea Presented to ED after Chinese food Past Hx unclear, no meds Physical exam HR 98, BP 142/82, RR 28, temp 36.0C JVP elevated, crackles, pulses 2+, legs warm and LEE+
CASE 1
74 year old female CXR = pending Labs = pending
prepare to provide your answer!
How confident are you that it is AHF?

1. 2. 3. 4. 5. <20% 21-40% 41-60% 61-80% >80%
How confident are you that it is AHF?

1. 2. 3. 4. 5. <20% 21-40% 41-60% 61-80% >80%
No right answer
AHF Dx Scoring systems

Predictor Elevated NT-proBNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4
2 2 2
Our Case ?
? 2
1
1 1 1
1 1 4 e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93

Baggish AL, et al. Am Heart J 2006; 151: 48-54].
CASE 1
74 year old female CXR = increased pulmonary markings c/w edema, no evidence of COPD Labs = troponin I 0.20
BNP 728 pg/ml Creatinine 130
AHF Dx Scoring systems

Predictor Elevated NT-proBNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4
2 2 2
Our Case 4
2 2
1
1 1 1
1 1 10 e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93

Baggish AL, et al. Am Heart J 2006; 151: 48-54].
CCS 2012
We recommend the use of a validated diagnostic scoring system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence). e.g. PRIDE score, Boston criteria This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation.
CCS 2012
We recommend that in the clinical scenario when the clinical diagnosis of AHF is of intermediate pre-test probability, NP level be obtained to rule-out (BNP <100 pg/ml; NT-proBNP <300 pg/ml) or rule-in (BNP >500 pg/ml; NT-proBNP >900 pg/ml if age 50-75 years, NT-proBNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF (Strong Recommendation, Moderate Quality Evidence)
CCS 2012: Practical Tips

A precipitating cause for AHF should be sought. An ECG and a chest x-ray should be performed within 2 hours of initial presentation.
Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin.
CCS 2012: Practical Tips

A transthoracic echocardiogram should be performed within 72 hours of presentation. For patients with a prior echocardiogram, another is not required unless there has been a significant change in clinical status requiring investigation, a lack of clinical response to appropriate therapy and/or it is greater than 12 months since the prior echocardiogram.
CASE 2
52 year old male with history of HF
Presented to ED after the Edmonton Oilers won the Stanley Cup
SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36.0c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0.15
Where on this table does this pt fit?
1
Dry and Warm Increasing Perfusion/ Cardiac Output
2
Wet and Warm
3
Dry and Cold
4
Wet and Cold
Increasing Congestion / PCWP

Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

1. 2. 3. 4. Dry and Warm Wet and Warm Dry and Cold Wet and Cold
0%
1
0%
2
0%
3
0%
4
1
Dry and Warm Increasing Perfusion/ Cardiac Output
2
Wet and Warm
3
Dry and Cold
4
Wet and Cold
Increasing Congestion / PCWP

Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804
Admit or discharge?
Treatment options?
CCS 2012: Oxygen

We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation >90% (Strong Recommendation, Moderate Quality Evidence). Values and Preferences: This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on longterm clinical usage of supplemental oxygen without supportive data.
CCS 2012: CPAP/BIPAP

We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate Quality Evidence). Values and Preferences: This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP may be appropriate for patients with persistent hypoxia and pulmonary edema.
CASE 2
52 year old male with history of HF
Presented to ED after the Edmonton Oilers won the Stanley Cup
SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36.0c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0.15
How much diuretic will you give and how?

1. 2. 3. 4. 5. IV lasix 20 mg bid IV lasix 40 mg bid IV lasix 80 mg bid IV lasix 10 mg/hour infusion Other choice
DOSE: Study Design

Acute Heart Failure (1 symptom AND 1 sign) <24 hours after admission 2x2 factorial randomization Low Dose (1 x oral) Low Dose (1x oral) Q12 IV bolus Continuous infusion High Dose (2.5 x oral) Q12 IV bolus High Dose (2.5 x oral) Continuous infusion
48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose e.g. Home dose = 40 mg BID Bolus = 80 (low) 200 (high) 72 hours Co-primary endpoints 60 days Clinical endpoints Heart Failure Guidelines Felker, NEJM 2011
DOSE: Co-Primary Endpoints
Efficacy:
Patient Global Assessment by visual analog scale over 72 hours using area under the curve
Safety:
Change in creatinine from baseline to 72 hours
DOSE: patient global assessment
DOSE: Death, Rehosp, ER visit
DOSE-AHF Conclusions
There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either: bolus vs. infusion or low vs. high No clinical differencesbut
High was associated with favorable trends:
Symptom relief (global assessment and dyspnea) Weight loss and net volume loss Proportion free from signs of congestion Reduction in NT-proBNP
CCS 2012: Diuretics

We recommend intravenous diuretics be given as first line therapy for patients with congestion (Strong Recommendation, Moderate Quality Evidence).
We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).
Diuretic dosing for ADHF

Creatinine clearance*
60 mL/min/1.73m2
Patient
New-onset HF or no maintenance diuretic therapy
Initial IV dose
Furosemide 20-40 mg 2-3 times daily Furosemide bolus equivalent to oral dose Furosemide 20-80 mg 2-3 times daily Furosemide bolus equivalent to oral dose
Maintenance dose
Lowest diuretic dose that allows for clinical stability is the ideal dose
Established HF or chronic oral diuretic therapy

< 60 mL/min/1.73m2 New-onset HF or no maintenance diuretic therapy Established HF or chronic oral diuretic therapy
*Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details. Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.
Practical Tips When Response to Diuretic is Suboptimal

Reevaluate the need for additional diuresis by assessing volume status Restrict NA+/H2O intake (and exercise caution reducing oral intake below 500 ml per 24 hours). Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, f urosemide 20-40 mg bolus then 5-20 mg/h) can be a useful strategy when other options are not available. Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolaz one 2.5-5 mg OB/BID or hydrochlorothiazide 25-50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have an adequate effect. Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diure tic resistance. Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficienc y.
For a persistently symptomatic patient with HF, what is next option?

1. 2. 3. 4. 5. 6. Higher dose lasix Different diuretic Add vasodilator Add inotropic agent Patience. Other choice
CCS 2012: Vasodilators

We recommend the following intravenous vasodilators, titrated to systolic blood pressure (SBP) > 100 mmHg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mmHg): a) Nitroglycerin (Strong Recommendation, Moderate Quality Evidence); b) Nesiritide (Weak Recommendation, High Quality Evidence); c) Nitroprusside (Weak Recommendation, Low Quality Evidence).
AHA 2012: RELAX-AHF, CARRESS
CCS 2012: Inotropes

We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine or milrinone (Strong Recommendation, High Quality Evidence). Values and Preferences These recommendations for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.
Do I stop the beta-blockers on admission?

Cohorts suggest continuing beta-blockers advantageous RCT: B-CONVINCED
Keep vs. Stop strategy in known HF pts on beta-blockers Keep was non-inferior to Stop. Does not delay clinical improvement Predicts staying on BB in the longer term
Eur Heart J 2009; 30:2186-92
RESYNCHRONIZATION THERAPY and DEVICES
Anique Ducharme, MD MSc FRCPC
Conflict Disclosures
The speaker has received fees/honoraria from the following sources:
Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical
None of the drugs, devices, or treatment modalities mentioned in this presentation are non approved indications.
Anique Ducharme, Institut de Cardiologie de Montral, Universit de Montral
A Case of Mild Heart Failure

61 years old female, BP 99/67 mmHg, HR 76 previous MI, bpm stable NYHA II, LVEF 25% K, 4.7 mEq/L; NT-proBNP 4500 pg/mL On optimal dose of lisinopril, eplerone and EKG: old anterior MI, LBBB bisoprolol, occasional QRS 155 ms. diuretics Has not been assessed for device Rx
You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next? 1. 2. 3. 4. Angiotensin receptor blocker ICD CRT CRT + ICD (CRT-D)
CRT in Patients with Mild HF Symptoms: MADIT-CRT
1820 pts, mostly NYHA II, CRT+ICD vs ICD alone Low risk population, annual mortality ~3% 40% reduction in HF events in CRT-ICD group
Moss et al, NEJM 2009
RAFT: Death or HF hospitalization

Outcome Primary outcome ICD (N=904) ICD-CRT (N=894) Hazard ratio (95% CI) P value
Death or hospitalization for HF

Secondary outcomes Death from any cause Hospitalization for HF
363 (40.3%)
297 (33.2%)
0.75 (0.640.87)
0.75 (0.620.91) 0.68 (0.560.83)
<0.001
236 (26.1%) 236 (26.1%)
186 (20.8%) 174 (19.5%)
0.003 <0.001
1800 pts, 80% NYHA II CRT-D vs ICD Median follow-up 40 months

Tang AS, et al. N Engl J Med 2010
CRT: Mortality reduction
Al-Majed et al, Annals of Internal Medicine 2011
CRT: HF Hosp reduction
Al-Majed et al, Annals of Internal Medicine 2011
Medical Therapy in Perspective

RAFT 1800 pts, 80% NYHA II CRT-D vs ICD; median f/u 40 months
EMPHASIS HF 2700+ patients, NYHA II Eplerenone vs Placebo; median f/u 21mo
25% reduction in mortality
25% reduction in mortality
Tang et al, N Engl J Med 2010
Zannad et al, N Engl J Med, 2010
Recommendation 2011 (Update)

We recommend the use of CRT in combination with an ICD for HF patients on optimal medical therapy with NYHA II HF symptoms, LVEF < 30%, and QRS duration > 150 ms. (Strong Recommendation, High Quality Evidence)
Practical tips
QRS> 150 ms based on a subgroup analysis of MADIT-CRT and RAFT studies
Most LBBB are >150 msec
The selection of patients should be individualized and based on risk features
CRT for Everyone?Maybe not

Not everyone will benefit
Non-response is ~30% depending on the definition of:
Death Hospitalization Failure to improve 1 NYHA functional class Failure to improve peak VO2 or 6 min walk distance Absence of reverse remodelling (LVESV or EF) Absence of improvement in dyssynchrony
Consider Risks vs Benefits: Real World

N = 1081 ICD replacements N = 713 Upgrade Procedures
Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010
Importance of Patient Selection

Much uncertainty persists:
Narrow QRS with mechanical dyssynchrony LV dysfunction and chronic RV pacing Atrial fibrillation and LBBB Right bundle branch block Asymptomatic patients
Class IV/Stage D patients
Recommendation
Routine CRT implantation is not currently recommended for patients with heart failure and narrow QRS (<120 ms)
Practical tips
Patients enrolled in CRT studies who show benefit have a QRS duration >150ms, on average. The benefit in patients with QRS 120ms to 150ms is less clear Echocardiography derived parameters of dyssynchrony cannot be recommended on a routine basis since clinical utility has not been established
Practical tip
The use of CRT may prevent worsening in patients with LV systolic dysfunction who require permanent pacing and who are expected to have a high burden of ventricular pacing
The ACEI-ARB-MRA Dilemma
Jonathan Howlett MD Disclosures at www.hfcc.ca
prepare to provide your answers!
Case 1. 34 year old female with NYHA FC II HF with LVEF 29% BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0 On BB, ACE, diuretic target doses. Which drug should you start next?
A. B. C. D.
ARB Aldo Inhibitor Neither Does not matter, going for device anyway
Case 2. 64 year old female with NYHA FC I HF with LVEF 29% BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2 On BB, ACE, CCB, diuretic target doses. Which drug should you start next?
A. B. C. D.
ARB Aldo Inhibitor Neither Both
Case 3. 84 year old female with NYHA FC IIIb HF with LVEF 29% BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7 On BB, ACE, Digoxin, diuretic optimal doses. Which drug should you start next?
A. B. C. D.
ARB Aldo Inhibitor Neither- I will use nitrates preferentially Both
When to Use ARBs as Add-on Therapy?

In patients with persistent HF symptoms, and who are at increased risk of HF hospitalization, despite optimal treatment with ACE inhibitors and betablockers (Class I, Level A)
CHARM Proportion of patients with CV death or hospital admission for CHF Val-HeFT Probability of freedom from combined endpoint
(All-cause mortality, cardiac arrest with resuscitation, hospitalization for worsening HF, or therapy with intravenous inotropes or vasodilators)
Pfeffer MA et al. Lancet 2003;363:759-66. Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.
Cohn JN et al. N Engl J Med 2001;345:1667-75.
CHARM-Added Permanent study drug discontinuations

Percent of patients Placebo 25 20 15 10 5 0 AE/ lab. abnorm. Hypotension Increased creatinine
24.2 18.3
Candesartan
What are the effects of Spiro?
7.8
3.1
4.5
4.1 0.7
3.4
Increased potassium
p=0.0003
p=0.079 p=0.0001 Heart Failure Guidelines
p<0.0001
2006 Recommendation
Patients with LVEF 30% and severe symptoms despite optimized other therapies (Class I, Level B)
Or with AHF with an LVEF less than 30% following acute myocardial infarction (Class IIa, level B)
69
EMPHASIS: Baseline Characteristics

Characteristic Mean age yr Female sex % Ischemic heart disease % Blood pressure mm Hg Atrial fibrillation or flutter % Diabetes mellitus no. (%) Serum Creatinine mg/dl Estimated GFR ml/min/1.73 m2 < 60 ml/min/1.73 m2 no. (%) Serum Potassium mmol/liter
Zannad, NEJM 2011; 364:11-21
Eplerenone (N=1364) 68.7 (7.7) 22.7% 70 124 17/75 10 30 34 1.14 (0.30) 71.2 (21.9) 32 4.3 (0.4)
Placebo (N=1373) 68.6 (7.6) 21.9% 68 12417/7510 32 29 1.16 (0.31) 70.4 (21.7) 35 4.3 (0.4)
EMPHASIS: Primary Endpoint

50
40
HR [95% CI] = 0.63 [0.54, 0.74] P < 0.0001

40
HR [95% CI] = 0.58 [0.47, 0.70] P < 0.0001

Heart Failure Hospitalization: Cumulative K-M Rate (%)
30
Primary Endpoint: Cumulative K-M Rate (%)
Placebo
30
356 (25.9)
Eplerenone
Placebo
253 (18.4)
Eplerenone
20
20
249 (18.3)
10
164 (12.0)
10
0 0 1 2 3
No. at Risk Placebo Eplerenone
Years from Randomization
1373 1364
848 925
512 562
199 232
No. at Risk Placebo Eplerenone
Years from Randomization
1373 1364
848 925
512 562
199 232
213 (15.5)
171 (12.5)
*Unadjusted HR, 0.78; 0.64, 0.95; p=0.01
71
Patient Follow-up and Dosing
Eplerenone
Placebo
Discontinuations in surviving patients (%)
16.3%
16.6%
Discontinuations for AE n (%)
188 (13.8%)
222 (16.2%)*
Mean dose at month 5 (mg/day)
39.1 13.8
40.8 12.9
* p = 0.09
Recommendation 2011
We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged > 55 years with LV systolic dysfunction (LVEF < 30%, or if LVEF is 30% and 35% with QRS duration >130 ms), and recent hospitalization for CVD or elevated BNP/NT-proBNP levels, who are on standard HF therapy
(Strong Recommendation, High-Quality Evidence)
Combination RAAS Blockade- Options Add an ARB

Mean BP reduction 5-7 / 3-5 mmHg Mean in creatinine < 30 umol/L Mean in potasssium 0.3 Mmol/L Reduction in CHF/CV Death in Mild/mod HF Evidence with triple therapy
Combination RAAS Blockade Add Spironolactone

Mean BP reduction -1 to +5/ _1+3 mmHg Mean in creatinine < 50 umol/L Mean in potasssium 0.5- 0.9 Mmol/L Trials stopped early in enhanced moderate HF No evidence in triple therapy
But we vote with our feet!
Fonarow, Circulation 2011.; p 1601-10
CHF Clinics Increased use of EBM versus Community- the First 1933 Patients
EB Therapy First visit from Community (n= 1155) Previously seen in clinic (n= 778) P value
Age (SD) LVEF (SD) ACE inhibitor (%)
62 (16) 30 (14) 79 25 49 49 15
63 (14) 31 (14) 81 60 66 58 30
ns ns ns 0.01 0.01 0.01 0.01
ACE inhibitor (% at target)

Diuretic (%) Beta Blocker (%) Aldo Antagonist (%)
J Card Fail, Volume 7, Issue 3 Suppl 2, p.90 (2001)
Impact of HF Clinic Care on LVEF in Canadians with HF

21 Clinics with data from 1999-2010 599 patients with LVEF data at 0, 1,2 years 74% male, 63% ischemic etiology
Baseline Assessment (SD) Year 1 follow up (SD) Year 2 follow up (SD) P value baseline to 2 years (SD)
Measurement
LVEF Improve by > 20% Improve by >10% ACE use ACE or ARB Beta blocker use Aldo Antagonist
Eur Heart J 2011;32 (suppl 1)
32 (14) baseline ACE inhibitor (%) 54% 70% 63% 21%
38 (15) 30 (14) 79 69% 93% 85% 35%
38 (14) 31 (14) 81 69% 95% 85% 45%
p< 0.001 p< 0.001 p< 0.001 p< 0.001 p< 0.001 p< 0.001 P< 0.001
Management of Patients with HF and Acute Intercurrent Medical Illness

HF patients with an acute dehydrating illness of any kind should undergo prompt evaluation (electrolytes, BUN, Crcl). If diarrhea or vomiting occurs, the aldosterone blocker should be stopped until resolution. Caution is also necessary when there are other potential causes of dehydration, including increase in diuretic dose.
Canadian Cardiovascular Society Consensus Conference recommendations update 2007 American College of Cardiology Foundation/American Heart Association practice guidelines 2009
79
Suggested addition.
Most of the time, the Aldosterone Antagonist is the way to go Monitoring is the most important aspect of Rx Triple therapy is discouraged outside special circumstances
Role for ARBs if:

Very high BP Difficulty with K+ high Cannot tolerate AA due to side effects Osteoarthritis?
Should all patients with HF exercise and how?
Eileen OMeara, M.D.
EXERCISE TRAINING IN CHRONIC HEART FAILURE

QUESTION 1. TRUE OR FALSE?
All patients with stable New York Heart Association (NYHA) class I-III should be considered for enrolment in a tailored exercise training program, in order to improve exercise tolerance and quality of life.
A. True B. False
The benefits of rehabilitation in HF

It is now well recognized that exercise-based cardiac rehabilitation programs for patients with HF improve exercise capacity, skeletal and respiratory muscle function, quality of life, autonomic function, biomarkers, and reduce depressive symptoms as well as cardiovascular risk factors. Piepoli MF et al. Eur J Heart Fail 2011; 13(4): 347357.
Vanhees L et al. Eur J Cardiovasc Prev Rehabil 2011.
Based on the results of prior studies of exercise training, the Canadian Cardiovascular Society has adopted recommendations that physical activity be considered for stable patients with systolic dysfunction. Canadian Cardiovascular Society consensus conference
recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006;22(1):2345.
The HF-ACTION trial

The HF-ACTION trial demonstrated no significant reduction in the combined endpoint of all-cause mortality or hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.841.02; P=0.13). After adjusting for 4 covariables associated with an increase in the primary endpoint and for HF etiology, exercise training was found to reduce the incidence of all-cause mortality or all-cause hospitalization by 11% (HR, 0.89; 95% CI, 0.810.99; P = 0.03). exercise training conferred modest but statistically significant improvements in self-reported health status.
OConnor CM et al. JAMA 2009; 301: 14391450. Flynn KE et al. JAMA 2009; 301: 14511459.
The case of Madame T

2007: 42 y.o. patient presents with EF 38% and sustained VT. No significant CAD on angio. Diagnosis: Familial cardiomyopathy 2007 - A defibrillator is implanted i.e. secondary prevention and medical therapy is optimized 2008: EF increased to 45% 2010: EF is 50% on echocardiogram 2010 Amiodarone is stopped since patient fears the side effects and EF is now normalized She undergoes a treadmill test prior to exercise training in November 2010
Sinus tachycardia then multiple PVCs then VT
Question 2. Select the best answer?

A. She had ischemia and this should have been investigated by another test B. The adrenaline surge during the test lead to ventricular tachycardia and the defibrillator shocks were appropriate C. The treadmill test should have been stopped before her heart rate reached the programmed VT zone so she would not receive shocks D. She should not be allowed to reach this level of exercise even if she did not have a defibrillator anyway E. She should have been on amiodarone or a higher dose of beta-blockers
PATIENT EVALUATION PRIOR TO AN EXERCISE PROGRAM

The following should be obtained prior to a tailored exercise training program:
An assessment of clinical status by a clinician experienced in the management of heart failure patients should be completed Establish if the patient has an ICD and if yes, verify if previous shocks have been delivered and note the programmed VT zone Exercise test (evaluate ischemia, arrhythmias, rate responses of patients with pacemakers, and determine training heart rate ranges) Non-cardiac causes of dyspnea or musculoskeletal disorders may limit exercise tolerance and should be evaluated
Madame T: Actions and Reactions

She complained to the hospital authorities and had to receive the help of a psychologist to cope with the fear of defibrillator shocks.
The technician was unaware of how to prepare a patient with a defibrillator for a treadmill test and the attending physician should have supervised more closely in preparation for the test.
A written protocol was made to ensure that this would not happen again. The patient was satisfied with the procedure. She began training again about 1 year later and still sees her cardiologist in that same hospital. Current EF is 45% (July 2012 echocardiogram)
Treadmill test protocol for patients with defibrillators

The indication for the treadmill test should be clearly described and the patient must be flagged as having a defibrillator Defibrillator programmation will be verified immediately prior to the treadmill test Maximal HR will be the programmed HR for VT therapy minus 20 beats per minute. The test should be stopped immediately as that HR is reached. All pharmacological treatments should be continued (especially beta-blockers and antiarrhythmics) No adjustment to the defibrillator programmation should be made in view of the treadmill test
Exercise Training in Stable HF is SAFE

A stepwise approach to exercise training in stable HF is suggested, including: Cardiopulmonary/exercise testing is used for safety assessment and exercise prescription.
Initial supervision ensures safety of the prescribed program and may help patients understand their limits. For patients who prefer home-based exercise, after a minimum of 6-8 supervised sessions, exercise training may continue with a home-based program.
Aerobic Exercise Training Prescription

Moderate-intensity continuous aerobic exercise training at rate of perceived exertion (RPE) 3-5 (Figure), 65-85% maximum heart rate, and 50-75% peak V02 is recommended in HF patients Exercise program schedule in stable patients should begin with aerobic exercise training, 10-15 minutes in duration, 2-3 days per week frequency, before gradually increasing training to a target of 30 minutes, 5 days per week. Walking, treadmill, and stationary cycling can be chosen as primary training modes. Moderate-intensity aerobic interval training may be incorporated into the ET program in selected, stable HF patients.
THANK YOU !
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CCS HEART FAILURE WORKSHOP

THE PRACTICAL MANAGEMENT OF HEART FAILURE 2012 UPDATE

Heart Failure Guidelines

Acute Heart Failure

What is heart failure?

Acute Heart Failure Syndrome (AHF):

Heart Failure Guidelines

Heart Failure Guidelines

Has care evolved?

Heart Failure Guidelines

Heart Failure Guidelines

74 year old female CXR = pending Labs = pending

Heart Failure Guidelines

prepare to provide your answer!

Heart Failure Guidelines

How confident are you that it is AHF?

Heart Failure Guidelines

How confident are you that it is AHF?

Heart Failure Guidelines

AHF Dx Scoring systems

1 1 4 e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93

Heart Failure Guidelines

Heart Failure Guidelines

AHF Dx Scoring systems

1 1 10 e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93

Heart Failure Guidelines

Heart Failure Guidelines

CCS 2012: Practical Tips

Heart Failure Guidelines

CCS 2012: Practical Tips

Heart Failure Guidelines

Heart Failure Guidelines

prepare to provide your answer!

Heart Failure Guidelines

Where on this table does this pt fit?

Increasing Congestion / PCWP

Heart Failure Guidelines

Where on this table does this pt fit?

Heart Failure Guidelines

Where on this table does this pt fit?

Increasing Congestion / PCWP

Heart Failure Guidelines

Heart Failure Guidelines

Heart Failure Guidelines

Heart Failure Guidelines

CCS 2012: Oxygen

Heart Failure Guidelines

CCS 2012: CPAP/BIPAP

Heart Failure Guidelines

Heart Failure Guidelines

prepare to provide your answer!

Heart Failure Guidelines

How much diuretic will you give and how?

Heart Failure Guidelines

DOSE: Study Design

DOSE: Co-Primary Endpoints

Heart Failure Guidelines

DOSE: patient global assessment

Heart Failure Guidelines

DOSE: Death, Rehosp, ER visit

Heart Failure Guidelines

Heart Failure Guidelines

CCS 2012: Diuretics